Know the problem of pain

My patients lie to me every day. Some tell me that they have been taking
their medications regularly when they haven't. Some say that they have
been eating a healthy diet and exercising for at least 30 minutes every
day and don't know where the extra pounds are coming from. Some lie that
they are using condoms every time they have sex, that they have quit
smoking, and if they drink alcohol at all, it's only a single glass of
wine with dinner. They bend the truth for many reasons: because they
want to please their doctor, because they don't like to admit lapses of
willpower, or because they are embarrassed to tell me that they can't
afford to pay for their medications. I forgive them; it's part of my job
to understand that patients (and health professionals) are only human.
The only lies that I find hard to forgive are the lies about pain.


Like many doctors, I have complicated feelings about prescribing for
chronic pain. On one hand, I recognize that relieving headaches,
backaches, arthritis and nerve pain has been a core responsibility of
the medical profession for ages. On the other hand, deaths and emergency
room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years,
and I have inherited many patients with narcotic addictions that
resulted from a prior physician's well-intentioned generosity with his
prescription pad.

Even worse, I've had patients I trusted turn out to be junkies in need
of a fix. An earnest, well-dressed young man once came to my office
complaining of a common chronic condition that, he said, had not been
relieved by high doses of over-the-counter painkillers. He convinced me
to to prescribe him narcotic pills, and didn't bat an eye when I asked
him to sign a pain contract
that required him to return every month for refills and only receive
prescriptions from me in person. For the better part of a year, he never
missed an appointment, and seemed genuinely receptive to unrelated
preventive care that I recommended based on his age and risk factors.
His deceit was exposed only after he stumbled, intoxicated, into an
acute care facility staffed by a doctor who knew me and requested an
early refill of a prescription for a different brand of painkillers
prescribed by a third doctor for another imaginary condition. My
colleague told him the gig was up, and I've never seen him again.


I believe that drug addiction is a disease.
So why do I find this patient's lies (and those from others like him)
so hard to forgive? Because they have consequences for people who are
truly in pain. For patients' convenience, I transmit virtually all
prescriptions electronically to the pharmacy, but I'm not allowed to do
this with "controlled substances" such as painkillers. Wary of
encouraging drug abuse, some insurers impose arbitrary limits on the
number of pills a patient may be prescribed in one month, which I can
only override by spending hours on the phone or not at all. One chain
pharmacy recently started demanding signed copies of chart notes that
included the pain-causing diagnosis before they would dispense
painkillers (a practice that I believe to be an illegal invasion of
privacy, but they didn't budge an inch when I told them so). And worst
of all, doctors like me who have been burned before are that much more
likely to view our patients with suspicion.


In the July issue of Health Affairs, Janice Schuster described a health odyssey
that began with a seemingly minor surgical procedure and ended with her
becoming "one of the estimated 100 million American adults who live
with chronic pain" - in this case neuropathic pain, or pain from nerve
damage that in my experience can be the most difficult type to treat.
She wrote about how health system restrictions designed to discourage
abuse created obstacles to her obtaining adequate pain relief, and about
a lack of compassion from her primary care physician (who "dismissed my
symptoms") and her surgeon (who "said again and again that he had not
heard of a patient experiencing such pain"). As the author of a popular
self-help book for persons facing serious illness, Schuster understood
better than most the public health crisis posed by prescription
painkillers, but that understanding offered little consolation as she
navigated "the maze of pain management" that has evolved to deal with
it:

Pain patients like me often feel trapped between the clinical
need to treat and manage pain and the social imperative to restrict
access to such drugs and promote public safety. ... When I am not
overwhelmed by pain, or depressed by it, I am furious at the attitudes I
encounter, especially among physicians and pharmacists. It has been
stigmatizing and humiliating. ... Surely, we can find better ways to
ease the suffering and devise treatments and strategies that do more
good than harm and that do not shame and stigmatize those who suffer.


A few of my colleagues have become so disillusioned with the dilemmas of
pain management that they have sworn off prescribing narcotic
painkillers entirely. As often as I've been tempted to take that path, I
won't abandon patients in pain, for whom the services of caring and
competent family physicians are needed now more than ever.

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Why are doctors still prescribing bed rest in pregnancy?

Maternity care providers have traditionally prescribed "bed rest," or
activity restriction, for a host of pregnancy complications (including
preterm contractions, short cervix, multiple gestation, and
preeclampsia) despite evidence that it does not improve maternal or
neonatal outcomes. On the other hand, prolonged activity restriction in
pregnancy increases risk for muscle atrophy, bone loss, thromboembolic
events, and gestational diabetes. Although it did not include this
practice in its Choosing Wisely "Five Things Physicians and Patients Should Question" list, the Society of Maternal and Fetal Medicine (SMFM) recently published a strongly worded position paper recommending against activity restriction in pregnancy for any reason.


This isn't the first time reviewers have examined the evidence for activity restriction and found it lacking; a 2013 summary
of several Cochrane reviews of therapeutic bed rest in pregnancy also
found such poor data to support the practice that the authors concluded
its use should be considered unethical outside of the context of a
randomized controlled trial.


The message isn't getting through to physicians or patients, though. A 2009 survey
of SMFM members found that 71 percent would recommend bed rest to
patients with arrested preterm labor, and 87 percent would advise bed
rest for patients with preterm premature rupture of membranes at 26
weeks gestation, even though most of them did not believe it would make
make any difference in the outcome (the most common answers were
"minimal benefit" and "minimal risk"). Unfortunately, the risk may be
more than minimal. Not only does activity restriction expose pregnant
women to harm, a secondary analysis of a randomized trial of preterm birth prevention found that nulliparous women with short cervices whose activity was restricted were actually more likely to deliver before 37 weeks' gestation than those who were not.


Similarly, a search of the terms "bed rest" on popular pregnancy websites Babyzone and Pregnancy.org yielded
the following statements that fly in the face of evidence: "Changing
the force of gravity usually helps minimize preterm labor." "It [bed
rest] helps keep blood pressure stable and low." "In most cases, bed
rest is used to help the body have the best chance to normalize." A
handout on WebMD provided a more balanced assessment:

Bed rest has been a way of treating pregnancy complications for
more than a hundred years. But there's a problem. While bed rest is a
common treatment, there's no proof that it helps. It doesn't seem to
protect your health or your baby's. In fact, bed rest has risks itself.
Doctors still prescribe it, but more because of tradition than good
evidence that it works.


The handout went on to advise patients to question their physicians
closely or get a second opinion if bed rest is recommended. That's
sensible advice. Doctors who are reluctant to abandon this useless and
potentially harmful maternity practice should consult the SMFM paper or the American Family Physician By Topic collections on Prenatal Care and Labor, Delivery, and Postpartum Issues, where no articles recommend activity restriction for pregnancy complications.

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Birth control pills over-the-counter: debate evidence, not politics

I've waited to address this sensitive topic until after the midterm
elections, when political slogans such as the phony "war on women" and
trumped-up threats to religious liberty were discarded like so many
campaign posters. It was curious to see the American College of
Obstetricians & Gynecologists (ACOG) and Planned Parenthood
attacking Republican Senate candidates for supporting over-the-counter birth control pills without a prescription -
a position that, if the pills were free or the candidates were
Democrats, they would probably have cheered. (When the American Academy
of Family Physicians quietly supported oral contraceptives over the counter earlier this year, it was careful to specify that such purchases be covered by health insurance.)


As outlined in a 2012 ACOG opinion paper,
the rationale for granting over-the-counter status to birth control
pills goes something like this: unintended pregnancies are common;
visiting a doctor for a prescription is inconvenient and unnecessary;
oral contraceptives are safer than many medications already available
without a prescription; women can screen themselves for
contraindications; and women wouldn't stop seeing doctors for other
preventive services. There are, however, very few studies that actually
support these arguments; much of the literature simply surveys what other countries do
regarding contraceptive access and assumes that outcomes are better (or
at least not worse). And surprisingly, there's no research whatsoever
that shows making oral contraceptives over-the-counter reduces
unintended pregnancies.


This hypothesis would be relatively straightfoward to test in a
randomized clinical trial. Enroll, say, five hundred non-pregnant,
sexually active, pre-menopausal women without contraindications to oral
contraceptives who don't want to become pregnant in the next 12 months.
Randomly assign half of them to receive birth control pills without a
prescription at a convenient pharmacy, and assign the other half to
obtain contraceptives the usual way, by requesting a prescription from
their family doctor or gynecologist. After a year, compare the numbers
of unintended pregnancies and adverse events (deep venous thromboses,
strokes, sexually transmitted infections) in each group. Other outcomes
could include contraceptive adherence, appropriate use, and use of
recommended preventive health care such as immunizations and screenings.


Why hasn't this study been performed already? Some physicians have told
me that this question doesn't need to be studied because it's obvious
that over-the-counter access to contraceptives would lead to fewer
pregnancies. Others have insinuated that even asking the question is
"anti-woman" and insensitive to the long history of gender bias in
health and men using fertility to control and oppress women.


I say bull. This isn't only a political question, it's also a scientific
one. Otherwise, why stop at putting oral contraceptives over the
counter? Why not, for example, make it easier for millions of women and
men with poorly controlled ("unintended") high blood pressure to treat
themselves by making anti-hypertensive drugs over-the-counter? In fact,
self-monitoring and self-titration of blood pressure medications is a
strategy that is being seriously considered in high-risk populations. A
recent randomized trial published in JAMA compared
this strategy to usual care in five hundred primary care patients with
hypertension and a history of stroke, coronary heart disease, diabetes,
or chronic kidney disease. After 12 months, the mean blood systolic
blood pressure of the intervention group was 9 points lower than that of
the control group, with no difference in adverse events.


The outcome of the hypertension study wasn't obvious. It might easily
have gone the other way. And for that reason, it was a question that
deserved to be rigorously studied. Similarly, over-the-counter birth
control need not be an evidence-free debate. Regardless of where you
stand on this issue personally or politically, it's time to stop with
the slogans and inform the discussion with science.

Read More

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All about Vitamin D

Find a Vitamin or Supplement

VITAMIN D

VITAMIN D Overview Information

Vitamin D is a vitamin. It can be found in small amounts in a few foods, including fatty fish such as herring, mackerel, sardines and tuna. To make vitamin D more available, it is added to dairy products, juices, and cereals that are then said to be “fortified with vitamin D.” But most vitamin D – 80% to 90% of what the body gets – is obtained through exposure to sunlight. Vitamin D can also be made in the laboratory as medicine.

Vitamin D is used for preventing and treating rickets, a disease that is caused by not having enough vitamin D (vitamin D deficiency). Vitamin D is also used for treating weak bones (osteoporosis), bone pain (osteomalacia), bone loss in people with a condition called hyperparathyroidism, and an inherited disease (osteogenesis imperfecta) in which the bones are especially brittle and easily broken. It is also used for preventing falls and fractures in people at risk for osteoporosis, and preventing low calcium and bone loss (renal osteodystrophy) in people with kidney failure.

Vitamin D is used for conditions of the heart and blood vessels, including high blood pressure and high cholesterol. It is also used for diabetes, obesity, muscle weakness, multiple sclerosis, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), asthma, bronchitis, premenstrual syndrome (PMS), and tooth and gum disease.

Some people use vitamin D for skin conditions including vitiligo, scleroderma, psoriasis, actinic keratosis, and lupus vulgaris.

It is also used for boosting the immune system, preventing autoimmune diseases, and preventing cancer.

Because vitamin D is involved in regulating the levels of minerals such as phosphorous and calcium, it is used for conditions caused by low levels of phosphorous (familial hypophosphatemia and Fanconi syndrome) and low levels of calcium (hypoparathyroidism and pseudohypoparathyroidism).

Vitamin D in forms known as calcitriol or calcipotriene is applied directly to the skin for a particular type of psoriasis.

If you travel to Canada, you may have noticed that Canada recognizes the importance of vitamin D in the prevention of osteoporosis. It allows this health claim for foods that contain calcium: "A healthy diet with adequate calcium and vitamin D, and regular physical activity, help to achieve strong bones and may reduce the risk of osteoporosis.” But the US version of this osteoporosis health claim does not yet include vitamin D.

How does it work?

Vitamin D is required for the regulation of the minerals calcium and phosphorus found in the body. It also plays an important role in maintaining proper bone structure.

Sun exposure is an easy, reliable way for most people to get vitamin D. Exposure of the hands, face, arms, and legs to sunlight two to three times a week for about one-fourth of the time it would take to develop a mild sunburn will cause the skin to produce enough vitamin D. The necessary exposure time varies with age, skin type, season, time of day, etc.

It’s amazing how quickly adequate levels of vitamin D can be restored by sunlight. Just 6 days of casual sunlight exposure without sunscreen can make up for 49 days of no sunlight exposure. Body fat acts like a kind of storage battery for vitamin D. During periods of sunlight, vitamin D is stored in fatty fat and then released when sunlight is gone.

Nevertheless, vitamin D deficiency is more common than you might expect. People who don’t get enough sun, especially people living in Canada and the northern half of the US, are especially at risk. Vitamin D deficiency also occurs even in sunny climates, possibly because people are staying indoors more, covering up when outside, or using sunscreens consistently these days to reduce skin cancer risk.

Older people are also at risk for vitamin D deficiency. They are less likely to spend time in the sun, have fewer “receptors” in their skin that convert sunlight to vitamin D, may not get vitamin D in their diet, may have trouble absorbing vitamin D even if they do get it in their diet, and may have more trouble converting dietary vitamin D to a useful form due to aging kidneys. In fact, the risk for vitamin D deficiency in people over 65 years of age is very high. Surprisingly, as many as 40% of older people even in sunny climates such as South Florida don’t have enough vitamin D in their systems.

Vitamin D supplements may be necessary for older people, people living in northern latitudes, and for dark-skinned people who need extra time in the sun, but don’t get it.

VITAMIN D Uses & Effectiveness

Effective for:

• Treating conditions that cause weak and painful bones (osteomalacia).
• Low levels of phosphate in the blood (familial hypophosphatemia).
• Low levels of phosphate in the blood due to a disease called Fanconi syndrome.
• Psoriasis (with a specialized prescription-only form of vitamin D).
• Low blood calcium levels because of a low parathyroid thyroid hormone levels.
• Helping prevent low calcium and bone loss (renal osteodystrophy) in people with kidney failure.
• Rickets.
• Vitamin D deficiency.

Likely Effective for:

• Treating osteoporosis (weak bones). Taking a specific form of vitamin D called cholecalciferol (vitamin D3) along with calcium seems to help prevent bone loss and bone breaks.
• Preventing falls in older people. Researchers noticed that people who don’t have enough vitamin D tend to fall more often than other people. They found that taking a vitamin D supplement reduces the risk of falling by up to 22%. Higher doses of vitamin D are more effective than lower doses. One study found that taking 800 IU of vitamin D reduced the risk of falling, but lower doses didn’t.
  
  Also, vitamin D, in combination with calcium, but not calcium alone, may prevent falls by decreasing body sway and blood pressure. This combination prevents more falls in women than men.
• Reducing bone loss in people taking drugs called corticosteroids.

Possibly Effective for:

• Reducing the risk of multiple sclerosis (MS). Studies show taking vitamin D seems to reduce women’s risk of getting MS by up to 40%. Taking at least 400 IU per day, the amount typically found in a multivitamin supplement, seems to work the best.
• Preventing cancer. Some research shows that people who take a high-dose vitamin D supplement plus calcium might have a lower chance of developing cancer of any type.
• Weight loss. Women taking calcium plus vitamin D are more likely to lose weight and maintain their weight. But this benefit is mainly in women who didn’t get enough calcium before they started taking supplements.
• Respiratory infections. Clinical research in school aged children shows that taking a vitamin D supplement during winter might reduce the chance of getting seasonal flu. Other research suggests that taking a vitamin D supplement might reduce the chance of an asthma attack triggered by a cold or other respiratory infection. Some additional research suggests that children with low levels of vitamin D have a higher chance of getting a respiratory infection such as the common cold or flu.
• Reducing the risk of rheumatoid arthritis in older women.
• Reducing bone loss in women with a condition called hyperparathyroidism.
• Preventing tooth loss in the elderly.

Possibly Ineffective for:

• Breast cancer. Many studies have looked at whether vitamin D can help prevent breast cancer, but their results have not always agreed. The best evidence to date comes from a large study called the Women’s Health Initiative, which found that taking 400 IU of vitamin D and 1000 mg of calcium per day does not seem to lower the chance of getting breast cancer. The possibility remains that high doses of vitamin D might lower breast cancer risk in younger women. But the doses needed would be so high that they might not be safe.
• High blood pressure.
• Improving muscle strength in older adults.
• Preventing bone loss in people with kidney transplants.

Insufficient Evidence for:

• Asthma. Some research suggests that people with asthma are more likely to have low vitamin D levels in the body. In children with asthma, taking a vitamin D supplement might reduce the chance of an asthma attack during a cold or other respiratory infection. But it is too soon to know if taking a vitamin D supplement can prevent or treat asthma symptoms.
• Heart disease. Research suggests that people with low levels of vitamin D in their blood are much more likely to develop heart disease, including heart failure, than people with higher vitamin D levels. However, taking vitamin D does not seem to extend the life of people with heart failure.
• Chronic obstructive pulmonary disease (COPD). Some research shows that people with COPD have lower than normal vitamin D levels. But there is not enough information to know if taking a vitamin D supplement can decrease symptoms of COPD.
• High cholesterol. People with lower vitamin D levels seem to be much more likely to have high cholesterol than people with higher vitamin D levels. Limited research shows that taking calcium plus vitamin D daily, in combination with a low-calorie diet, significantly raises “good (HDL) cholesterol” and lowers “bad (LDL) cholesterol” in overweight women. But taking calcium plus vitamin D alone, does not reduce LDL cholesterol levels.
• Gum disease. Higher blood levels of vitamin D seem to be linked with a reduced risk of gum disease in people 50 years of age or older. But, this doesn’t seem to be true for adults younger than 50.
• Diabetes. People with lower vitamin D levels are significantly more likely to have type 2 diabetes compared to people with higher vitamin D levels. But, there is no reliable evidence that taking vitamin D supplements can treat or prevent type 2 diabetes.
• Premenstrual syndrome (PMS). There is some evidence that getting more vitamin D from the diet might help to prevent PMS or reduce symptoms. Taking vitamin D supplements might help reduce symptoms but doesn't seem to help prevent PMS.
• A blood cell disease called myelodysplastic syndrome.
• A muscle disease called proximal myopathy.
• Colorectal cancer.
• Warts.
• Bronchitis.
• Asthma.
• Breathing disorders.
• Metabolic syndrome.
• Muscle pain caused by medications called "statins."
• Vaginal atrophy.
• Other conditions.

More evidence is needed to rate vitamin D for these uses.

VITAMIN D Side Effects & Safety

Vitamin D is LIKELY SAFE when taken by mouth in recommended amounts. Most people do not commonly experience side effects with vitamin D, unless too much is taken. Some side effects of taking too much vitamin D include weakness, fatigue, sleepiness, headache, loss of appetite, dry mouth, metallic taste, nausea, vomiting, and others.

Taking vitamin D for long periods of time in doses higher than 4000 units per day is POSSIBLY UNSAFE and may cause excessively high levels of calcium in the blood. However, much higher doses are often needed for the short-term treatment of vitamin D deficiency. This type of treatment should be done under the supervision of a healthcare provider.

Special Precautions & Warnings:   

Pregnancy and breast-feeding: Vitamin D is LIKELY SAFE during pregnancy and breast-feeding when used in daily amounts below 4000 units. Do not use higher doses. Using higher doses might cause serious harm to the infant.

Kidney disease: Vitamin D may increase calcium levels and increase the risk of “hardening of the arteries” in people with serious kidney disease. This must be balanced with the need to prevent renal osteodystrophy, a bone disease that occurs when the kidneys fail to maintain the proper levels of calcium and phosphorus in the blood. Calcium levels should be monitored carefully in people with kidney disease.

High levels of calcium in the blood: Taking vitamin D could make this condition worse.

“Hardening of the arteries” (atherosclerosis): Taking vitamin D could make this condition worse.

Sarcoidosis: Vitamin D may increase calcium levels in people with sarcoidosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.

Histoplasmosis: Vitamin D may increase calcium levels in people with histoplasmosis. This could lead to kidney stones and other problems. Use vitamin D cautiously.

Over-active parathyroid gland (hyperparathyroidism): Vitamin D may increase calcium levels in people with hyperparathyroidism. Use vitamin D cautiously.

Lymphoma: Vitamin D may increase calcium levels in people with lymphoma. This could lead to kidney stones and other problems. Use vitamin D cautiously.

VITAMIN D Interactions 

Moderate Interaction be cautious with this combination

• Aluminum interacts with VITAMIN D

Aluminum is found in most antacids. Vitamin D can increase how much aluminum the body absorbs. This interaction might be a problem for people with kidney disease. Take vitamin D two hours before, or four hours after antacids.

• Calcipotriene (Dovonex) interacts with VITAMIN D

Calcipotriene is a drug that is similar to vitamin D. Taking vitamin D along with calcipotriene (Dovonex) might increase the effects and side effects of calcipotriene (Dovonex). Avoid taking vitamin D supplements if you are taking calcipotriene (Dovonex).

• Digoxin (Lanoxin) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Calcium can affect the heart. Digoxin (Lanoxin) is used to help your heart beat stronger. Taking vitamin D along with digoxin (Lanoxin) might increase the effects of digoxin (Lanoxin) and lead to an irregular heartbeat. If you are taking digoxin (Lanoxin), talk to your doctor before taking vitamin D supplements.

• Diltiazem (Cardizem, Dilacor, Tiazac) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Calcium can affect your heart. Diltiazem (Cardizem, Dilacor, Tiazac) can also affect your heart. Taking large amounts of vitamin D along with diltiazem (Cardizem, Dilacor, Tiazac) might decrease the effectiveness of diltiazem.

• Verapamil (Calan, Covera, Isoptin, Verelan) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Calcium can affect the heart. Verapamil (Calan, Covera, Isoptin, Verelan) can also affect the heart. Do not take large amounts of vitamin D if you are taking verapamil (Calan, Covera, Isoptin, Verelan).

• Water pills (Thiazide diuretics) interacts with VITAMIN D

Vitamin D helps your body absorb calcium. Some "water pills" increase the amount of calcium in the body. Taking large amounts of vitamin D along with some "water pills" might cause to be too much calcium in the body. This could cause serious side effects including kidney problems.

Some of these "water pills" include chlorothiazide (Diuril), hydrochlorothiazide (HydroDIURIL, Esidrix), indapamide (Lozol), metolazone (Zaroxolyn), and chlorthalidone (Hygroton).

Minor Interaction be watchful with this combination

• Cimetidine (Tagamet) interacts with VITAMIN D

The body changes vitamin D into a form that it can use. Cimetidine might decrease how well the body changes vitamin D. This might decrease how well vitamin D works. But this interaction probably isn't important for most people.

• Heparin interacts with VITAMIN D

Heparin slows blood clotting and can increase the risk of breaking a bone when used for a long period of time. People taking these medications should eat a diet rich in calcium and vitamin D.

• Low molecular weight heparins (LMWHS) interacts with VITAMIN D

Some medications called low molecular weight heparins can increase the risk of breaking a bone when used for a long periods of time. People taking these medications should eat a diet rich in calcium and vitamin D.

These drugs include enoxaparin (Lovenox), dalteparin (Fragmin), and tinzaparin (Innohep).

VITAMIN D Dosing                  

The following doses have been studied in scientific research:

BY MOUTH:

• For preventing osteoporosis and fractures: 400-1000 IU per day has been used for older adults. Some experts recommended higher doses of 1000-2000 IU daily.
• For preventing falls: 800-1000 IU/day has been used in combination with calcium 1000-1200 mg/day.
• For preventing multiple sclerosis (MS): long-term consumption of at least 400 IU per day, mainly in the form of a multivitamin supplement, has been used.
• For preventing all cancer types: calcium 1400-1500 mg/day plus vitamin D3 (cholecalciferol) 1100 IU/day in postmenopausal women has been used.
• For muscle pain caused by medications called "statins": vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) 50,000 units once a week or 400 IU daily.
• For preventing the flu: vitamin D (cholecalciferol) 1200 IU daily.

Most vitamin supplements contain only 400 IU (10 mcg) vitamin D.

The Institute of Medicine publishes recommended daily allowance (RDA), which is an estimate of the amount of vitamin D that meets the needs of most people in the population. The current RDA was set in 2010. The RDA varies based on age as follows: 1-70 years of age, 600 IU daily; 71 years and older, 800 IU daily; pregnant and lactating women, 600 IU daily. For infants ages 0-12 months, an adequate intake (AI) level of 400 IU is recommended.

Some organizations are recommending higher amounts. In 2008, the American Academy of Pediatrics increased the recommended minimum daily intake of vitamin D to 400 IU daily for all infants and children, including adolescents. Parents should not use vitamin D liquids dosed as 400 IU/drop. Giving one dropperful or mL by mistake can deliver 10,000 IU/day. The US Food and Drug Administration (FDA) will force companies to provide no more than 400 IU per dropperful in the future.

The National Osteoporosis Foundation recommends vitamin D 400 IU to 800 IU daily for adults under age 50, and 800 IU to 1000 IU daily for older adults.

The North American Menopause Society recommends 700 IU to 800 IU daily for women at risk of deficiency due to low sun (e.g., homebound, northern latitude) exposure.

Guidelines from the Osteoporosis Society of Canada recommend vitamin D 400 IU per day for people up to age 50, and 800 IU per day for people over 50. Osteoporosis Canada now recommends 400-1000 IU daily for adults under the age of 50 years and 800-2000 IU daily for adults over the age of 50 years.

The Canadian Cancer Society recommends 1000 IU/day during the fall and winter for adults in Canada. For those with a higher risk of having low vitamin D levels, this dose should be taken year round. This includes people who have dark skin, usually wear clothing that covers most of their skin, and people who are older or who don't go outside often.

Many experts now recommend using vitamin D supplements containing cholecalciferol in order to meet these intake levels. This seems to be more potent than another form of vitamin D called ergocalciferol.

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